The need for innovative strategies to improve immunisation services in rural Zimbabwe

Addmore Chadambuka, Anderson Chimusoro, Tsitsilina Apollo, Mufuta Tshimanga, Olivia Namusisi and Elizabeth T. Luman1

Gokwe South, a rural district in Midlands Province, Zimbabwe, reported the lowest rate of immunisation coverage in the country in 2005: 55 per cent of children vaccinated with three doses of diphtheria/pertussis/tetanus vaccine (DPT3) and 35 per cent dropout between the first and third dose of DPT. In January 2007, the authors assessed local barriers to immunisation and proposed strategies to improve immunisation rates in the district, in the face of nationwide economic and political challenges. A situational analysis was performed to assess barriers to immunisation using focus-group discussions with health workers, key informant interviews with health man-agement and community leaders, and desk reviews of records. Responses were categorised and solutions proposed. Health workers and key informants reported that immunisation service delivery was hampered by insufficient availability of gas for cold-chain equipment, limited transport and fuel to conduct basic activities, and inadequate staff and supervision. Improving coverage will require prioritising gas for vaccine cold-chain equipment, identifying reliable trans-portation or alternative transportation solutions, and increased staff, training and supervision. Local assessment is critical to pinpointing site-specific barriers, and innovative strategies are needed to overcome existing contextual challenges.

Keywords: dropout rate, Gokwe South, immunisation, Midlands Province, vaccination coverage, Zimbabwe

IntroductionCurrent crisisPrior to the mid-1990s, Zimbabwe had one of the strongest economies in Sub-Saharan Africa, with a per capita gross domestic product (GDP) of more than 700 USD in 1996 (United Nations Statistics Division, 2008). Since that time, political instability and economic collapse have led to spiralling inflation, reaching 231 million per cent (by far the highest in the world) (Capp, 2009), more than 70 per cent un-employment, 80 per cent of the population living in poverty (AlertNet, 2008), and critical shortages of basic commodities, such as fuel and food (Central Intelligence Agency, 2008; Levine, 2008). It is estimated that Zimbabwe experienced the greatest economic decline of all countries worldwide between 1994 and 2004 (Teslik, 2008): real GDP contracted by 40 per cent between 1999 and 2007 and by a further 14 per cent in 2008 (International Monetary Fund, 2009; World Bank, 2009) (see Figure 1) due to the seizure of commercial farms, hyperinflation, price distortions resulting

doi:10.1111/j.1467-7717.2011.01246.x

Disasters, 2012, 36(1): 161−173. © 2012 The Author(s). Disasters © Overseas Development Institute, 2011Published by Blackwell Publishing, 9600 Garsington Road, Oxford, OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA

AddmoreChadambukaetal.162

Figure 1 Trends in vaccination coverage*, dropout** and per capita GDP in Zimbabwe,

1982–2007

Notes:* Percentage of children who received three doses of DPT vaccine. ** Proportion of children who received the first dose of DPT but not the third dose.

Source: International Monetary Fund (2009); World Bank (2009).

from exchange rate regulations, and the collapse of investor confidence (Coorey et al., 2000). Once known as the ‘breadbasket of southern Africa’ (Levine, 2008), Zimbabwe now faces widespread famine, relying on food imports and the provi-sion of humanitarian assistance to five million vulnerable people, mostly in rural areas (World Bank, 2009). With previously the highest literacy rate in Africa, it is estimated that only 20 per cent of Zimbabwe’s children now attend school (Capp, 2009). Along with economic collapse there has been a deterioration of the health care system. Zimbabwe’s only teaching hospital and medical school shut down in 2008 (Anonymous, 2009), and many doctors and nurses have left the country due to poor working conditions, a lack of supplies, and low or nonexistent wages (Truscott, 2009); one doctor reported earning USD 0.32 per month (Anonymous, 2009). It is estimated that only about 800 doctors remain to care for Zimbabwe’s 12 million people (Meldrum, 2008). The World Medical Association has noted violations of human rights, failure to provide basic health care resources, denial of health care for and state torture of political opponents, and threats of violence against physicians and health care workers (World Medical Association, 2007); Physicians for Human Rights (2009) has called for the International Criminal Court to investigate the health crisis in Zimbabwe as a crime against humanity. Disintegration of the health care system has produced a public health crisis (World Medical Association, 2007), and basic health statistics are in decline (WHO, 2006,

TheneedforinnovativestrategiestoimproveimmunisationservicesinruralZimbabwe 163

2009a). According to the World Health Organization (WHO), life expectancy at birth, once one of the highest in Africa, decreased from 62 years in 1990 to 36 years in 2008—the lowest in the world. Under-five mortality rose 61 per cent between 1990 and 2005, from 80 to 129 deaths per 1,000 live births. Maternal mortality nearly doubled between 1990 and 2000, rising from 570 to 1,100 deaths per 100,000 live births. Overall adult mortality rates more than doubled between 1990 and 2006, increasing from 286 to 751 deaths among adults aged between 15 and 60 years per 1,000 population—the highest in Africa. The HIV/AIDS (human immunodeficiency virus/acquired immune deficiency syndrome) epidemic also has hit Zimbabwe hard, with the second-highest rate of deaths per 100,000 population in the region, killing some 3,000 people each week (Meldrum et al., 2008). Moreover, Zimbabwe has experienced of one of the worst cholera epidemics in history, due to the breakdown of water and sewage systems, coupled with the inability of the decimated public health system to mount a suffi-cient response (Koenig, 2009). From August 2008–March 2009, as many as 90,000 people were infected, and more than 4,000 have died (WHO, 2009b), yielding a case fatality rate of 5.7 per cent—as high as nine per cent in some rural areas—compared to a target of less than one per cent (United Nations Statistics Division, 2008).

Immunisation programmeZimbabwe’s Expanded Programme on Immunisation (ZEPI) was launched in 1982 to reduce morbidity and mortality from six vaccine preventable diseases (Ministry of Health and Child Welfare, 2005a). The programme achieved remarkable results during its first 15 years, improving vaccination coverage of children receiving three doses of diphtheria/tetanus/pertussis vaccine (DPT3) from 46 per cent in 1982 to 90 per cent in 1996—based on estimates of WHO and the United Nations Children’s Fund (UNICEF)—and reducing dropout rates (proportion of children who received the first but not the third dose of DPT) during that time period from 35 to 6 per cent (see Figure 1) (WHO and UNICEF, 2008). However, DPT3 coverage declined to 67 per cent and dropout increased to 16 per cent between 1996 and 2003. These changes corresponded to the general economic deterioration in the country and re-duced government spending for health services, exacerbated by decreased support from Zimbabwe’s traditional external immunisation programme partners (Ministry of Health and Child Welfare, 2004a). Since 2003, ZEPI has received support from the Global Alliance for Vaccines and Immunisation (GAVI) for training health workers, purchasing cold-chain gas, and acquiring vaccine supply. The goals of the WHO/UNICEF ‘Global Immunisation Vision and Strategy 2006–2015’ include all countries attaining 90 per cent routine vaccination coverage nationally with at least 80 per cent in all districts by 2010 (WHO and UNICEF, 2005). In 2004, WHO’s ‘Reaching Every District’ strategy was introduced in 10 of Zimbabwe’s 59 districts. This strategy was designed to help countries achieve global immunisation objectives (WHO, 2004), by enumerating prac-tical activities to improve immunisation systems from the district level upwards. However, immunisation services remained hindered by high staff turnover rates,

AddmoreChadambukaetal.164

transport and fuel shortages, poor forecasting of logistics and supplies, inadequate timeliness in reporting routine immunisation data, and insufficient collaboration with local communities (Ministry of Health and Child Welfare, 2000, 2005b). As a result, national coverage with DPT3 declined further to 62 per cent in 2007, with dropout rising to 19 per cent. Gokwe South District in Midlands Province is an underdeveloped rural district with a population of 251,405. It has 31 health facilities that provide immunisation services, but a large proportion of its population is difficult to access due to poor road networks, and therefore is accessed through outreach services. Gokwe South reported the lowest immunisation coverage in Zimbabwe in 2005, with 55 per cent of children vaccinated with DPT3 (Ministry of Health and Child Welfare, 2005c). This figure represents a decrease in coverage from 64 per cent in 2004 (Ministry of Health and Child Welfare, 2005d), and is well below the national and global target of 80 per cent in all districts. In addition, dropout was 35 per cent in 2005, com-pared to the national average of 24 per cent; a dropout rate of more than 10 per cent is considered unacceptable. Low coverage and high dropout rates reflect problems of demand for vaccination services and/or the inability of the immunisation programme to supply adequate services (Ministry of Health and Child Welfare, 2004b). In an effort to increase vaccination coverage and reduce dropout in Gokwe South and throughout Zimbabwe, the authors conducted, in January 2007, an in-depth assessment of barriers and challenges to the provision of immunisations. The poten-tial strategies to address these problems are discussed below in the context of existing (as of July 2008) limitations facing the country.

MethodsInformation on barriers to immunisation service delivery was obtained from health workers and key informants throughout Gokwe South. Ten of the 31 health facili-ties in the district were randomly selected to participate in the survey. Investigators invited health facility staff present on the day of the survey (15–26 January 2007), along with village health workers (VHW) in the facility’s catch-ment area, to participate in focus-group discussions. In all, 10 focus groups were assembled, composed of 8–12 male and female health workers of different ages in the selected facilities. These health workers also identified health management and community leaders as key informant candidates; investigators invited them to attend the sessions—a total of 23 from 10 communities were interviewed. Verbal consent was obtained from all participants, and pseudonyms were used to protect anonymity. A locally-adapted version of WHO’s ‘Common Assessment Tool for Immunisation Services’ (WHO, 2002) was used to elicit responses from focus-group participants and key informants on the availability of supplies and transport, the adequacy of human resources, the level of community involvement, and financial and logistical constraints. Possible solutions and strategies were discussed. Focus-group discussion data were transcribed by two moderators and read for content, noting quality and patterns of responses; emerging themes were labelled and summarised.

TheneedforinnovativestrategiestoimproveimmunisationservicesinruralZimbabwe 165

Desk reviews of immunisation records also were performed, and equipment and supplies were checked.

Results Availability of suppliesFour of the 31 health facilities in the district had electricity, whereas the remaining 27 relied on gas to power cold-chain equipment (see Table 1). Among the 10 facili-ties surveyed, six relied on gas and all six had experienced gas stock-outs in 2006, resulting in discontinuation of routine immunisation services for between three and 11 months (see Table 1). During these gas stock-outs, vaccination services were dis-continued and vaccine was returned to district cold-storage facilities to ensure its continued viability. These facilities have a total catchment population of 5,878 children aged from 0–12 months. Thus, with five vaccination visits per child (at birth and at three, four, five and nine months of age), the selected health facilities would conduct an expected 29,390 vaccination visits during the year. Of the 29,390 vaccina-tion visits expected to occur during the year 2006 at the 10 facilities, 19 per cent were directly affected by these gas shortages (see Table 1). In addition, outreach sessions

Table 1 Effect of gas shortages in 10 randomly selected health facilities in Gokwe

South District, Zimbabwe, 2006

Health facility Power source Children aged 0–12 months

Expected number of routine immunisation visits (five per child)*

Number of months that routine immunisation services were conducted during 2006

Estimated number of visits directly affected by missed immunisation sessions

Sasame Mission Electricity 420 2,100 12 0

DistrictHospital Electricity 2,088 10,440 12 0

Kana Mission Electricity 714 3,570 12 0

Manoti Electricity 636 3,180 7 1,325

Chemahororo Gas 324 1,620 8 540

Gwanika Gas 576 2880 8 960

Gawa Gas 420 2,100 7 875

Sai Gas 240 1,200 9 300

Huchu Gas 204 1,020 7 425

Musita Gas 256 1,280 1 1,173

Notes:

* Recommended (five per child) at birth and at three, four, five and nine months of age.

Data were collected from the health facilities during the study period.

AddmoreChadambukaetal.166

often were cancelled or postponed, limiting opportunities for children to receive the necessary vaccinations. This had an indirect effect: health workers reported that mothers had low confidence in the predictability of the sessions at both fixed and outreach posts, reducing the number of clients presenting for immunisation when sessions did occur.

Mothers have gathered several times and the ZEPI team never turned up. They now do not believe when we tell them about the team’s next visit. They start gathering when they see the ZEPI vehicle on site.

– Village health worker

Immunisation refrigerators were reported to be in satisfactory condition at all of the health facilities visited and health workers monitored and recorded cold-chain temperatures daily when power was available. All of the facilities either had stock books or stock cards to monitor their supplies; vaccine forecasting, ordering and availability were satisfactory. No sites reported experiencing stock-outs of vaccine.

We use the number of children vaccinated to project and order vaccines for the next month.

– Urban nurse

Transportation and communication

Two public health vehicles were available at the district level, but were shared among many departments and also were used as ambulances; consequently, vehicles were not reliably available for routine immunisation and outreach activities. Furthermore, fuel shortages were reported to be a major problem in Gokwe South District, as well as throughout the rest of Zimbabwe, limiting the frequency and distance of travel. Staff at some facilities indicated a willingness to use bicycles or motorbikes for outreach if they were made available.

We have a bicycle here, but it has no tyres and tubes, which we could use for ZEPI outreach.

– Rural nurse

I am willing to get trained in riding the motorbike and ride for outreach. That will ease pressure on the district and give me more responsibility for my area.

– Rural nurse

There is a motorbike here which we can use. The problem is fuel availability. If fuel is available, we can team up with the nurse to the outreach points and while immunisation is in progress I will carry out my activities there also.

– Environmental health technician

TheneedforinnovativestrategiestoimproveimmunisationservicesinruralZimbabwe 167

Most facilities had no means of communication and depended on public transport to send their messages and reports to the district headquarters. In a few instances, messages were relayed using police radio communication. All facilities used influ-ential leaders and schools to disseminate information to their communities.

Human resources, supervision and partners

Each health facility was designed to be staffed by two nurses, a nurse aide, and an environmental health technician. Four of the 10 facilities surveyed were fully staffed, five facilities had one nurse, and the remaining facility had none. These staffing levels were thought by workers to be insufficient for providing routine immunisa-tion services at both fixed post and outreach points. Furthermore, respondents said that most nurses responsible for immunisation were inexperienced and lacked suffi-cient training, although some technical input was given during district health team meetings and supervisory visits. Supervision was also reported to be inadequate. Three key informants said that, for the most part, very little time was spent on supervision at each facility, because supervisors needed to visit many facilities whenever they were able to secure transport.

The supervisors rarely visit us, and when they do they are always in a hurry. We hardly have time to interact while they check on what we are doing.

– Rural nurse

Key informants and focus groups identified several development partners (such as Care International and Concern Worldwide) that were working in the area, including one (Population Service International) that was actively supporting health activities.

Immunisation activities

It was evident from the focus groups that staff at all 10 facilities knew their hard-to-reach and underserved populations, as well as immunisation objectors. Seven facilities had plans for addressing the needs of under-served children. However, there was little feedback from higher to lower levels. All focus groups reported that children could receive immunisation services at any health facility without restrictions. All 10 facilities maintained routine immunisation registers to enable follow-up of defaulters (that is, dropouts), although some registers were not updated routinely and defaulter tracing was conducted rarely. Vaccination monitoring charts were available at all of the health facilities and the charts were current at seven of the 10 facilities. Missed opportunities for vaccination were noted in five facilities where vaccine was withheld if too few children for a multi-dose vial attended the vaccination session.

We are not constantly updating the ZEPI registers and informing village health workers to trace defaulters because we have not done any immunisation in the past three months.

– Rural nurse

AddmoreChadambukaetal.168

All 10 facilities had health committees that were involved in a variety of activities, ranging from raising money for nurses to collect vaccines to information dissemination.

DiscussionIn the midst of a complex humanitarian emergency, the remaining dedicated health care workers in Zimbabwe struggle to provide needed care—curative and preven-tive (Anonymous, 2008). On top of existing public health crises, including anthrax, cholera, HIV/AIDS and malnutrition (Physicians for Human Rights, 2009), the coun-try can little afford outbreaks of vaccine-preventable diseases, especially measles, which is one of the primary causes of child morbidity and mortality in complex emergencies (Toole et al., 1989; Moss et al., 2006). Thus, ensuring that the routine immunisation programme continues to run efficiently and effectively is a high pri-ority for Zimbabwe’s public health programme in the current situation. Through focus-group discussions and key informant interviews, the research team was able to identify several barriers to vaccination in this rural district of Zimbabwe, including insufficient availability of gas for cold-chain equipment, limited trans-port and fuel to conduct basic activities, unreliable communication channels, and inadequate staff and supervision. These problems are not unique to Gokwe South District, and stem from the larger national-level issues that are beyond the scope of the routine immunisation programme to solve. However, it may be possible to cir-cumvent these constraints by adopting simple strategies to improve the functioning of the immunisation programme (see Table 2).

Table 2 Barriers to vaccination and potential strategic solutions, Gokwe South District,

Zimbabwe, 2006

Barrier Strategy

Gas shortages Prioritisegasforvaccinecoldchaintoensureaconsistentsupplyofusablevaccineatallhealthfacilities.

Lackofreliabletransportfor outreach services

Usealternativemeansoftransportation(bicycle,motorbike,publictransportandwalking).Sharetransportwithotherprogrammes.

Lackofcommunicationequipment Sendmessagestodistrictheadquartersvianon-standardchannels,suchaspoliceradioormessenger.Disseminatecommunityinformationthroughlocalleadersand schools.

Staffingshortages Evaluatestaffingneeds.Rotateteamstounderstaffedfacilitiesandsolicitlocalvolunteerstohelpwithnon-technicalduties,suchascrowdcontrol,defaultertracing and registration.

Inadequatetrainingofstaff Provideadditionaltrainingondefaultertracing,reducingmissedopportunitiesforvaccination,andtimemanagement.

Lackofsupervision Re-emphasisetheimportanceofsupervision,andincreasethequalityandquantityofsupervisoryvisits.

Generallackofresources Buildpartnershipswithotherprogrammes,conductintegratedservicedelivery,and encourage active community participation.

TheneedforinnovativestrategiestoimproveimmunisationservicesinruralZimbabwe 169

The problem of gas shortages for maintaining cold chain is likely to get worse before it gets better, as interruptions to the electricity supply are occurring with increasing frequency and for longer periods of time. The cold-chain function is critical for maintaining the viability of vaccines and the continuity of services. Consequently, increasing protection from vaccine preventable diseases in children will require prioritisation of gas for vaccine cold chain in order to ensure a consistent supply of usable vaccine at all health facilities. ZEPI is committed to making vaccines available to all children; effective outreach is required to provide access for those living in remote areas. Reliable transportation is therefore a basic need of the programme—previous studies have demonstrated an inverse relationship between vaccination coverage and distance from vaccination clinics (Bosu, 1997; WHO and UNICEF, 2005). Given that vehicles and fuel are likely to remain in short supply in the foreseeable future, vaccination staff may need to consider alternative means of transportation. Depending on local situations, outreach on foot, by bicycle or motorbike, or via public transport may be a cost-effective and feasible alternative to automobiles. Reliable channels of communication between immunisation clinics and district-level management is critical to ensure that health workers can submit reports as well as request assistance and supplies when needed. Communication from the district to health centres allows district managers to provide feedback, assist with brain-storming solutions to immediate problems, and to improve worker morale and reduce perceived isolation. If standard channels of communication are unreliable or nonexistent, alternative solutions must be identified, such as the use of police radio or messenger. Equally important is the ability of health workers to communicate with the community, often referred to as ‘social mobilisation’. The WHO/UNICEF ‘Global Immunisation Vision and Strategy 2006–2015’ suggests that vaccination pro-grammes should ‘assess existing communication gaps in reaching all communities and develop and implement a communication and social mobilization plan’ (WHO and UNICEF, 2005, p. 33). Effective communication with communities is espe-cially critical when services are sporadic due to gas or vaccine stock-outs, or when outreach sessions need to be cancelled. In addition to formal modes of mass com-munication, working through local alternatives, such as social or religious leaders, community groups and schools, may be an effective means of increasing awareness among the community. The research team found that many health facilities lacked the basic staffing re-quired to conduct routine vaccination services. If other nearby districts have sufficient staff, evaluation of staffing levels and re-appropriation may be feasible. However, as staffing shortages in Zimbabwe are widespread, rotating teams to cover understaffed facilities may help to mitigate the problems. In addition, local volunteers could be recruited to assist with non-technical duties, such as ensuring crowd control and efficient patient flow during immunisation sessions, registering patients, and follow-ing up with defaulters to reduce dropout. Adequately trained human resources are an essential requirement for improving vaccination coverage (Omutanyi and Mwanthi, 2005); training of health workers in

AddmoreChadambukaetal.170

basic programmatic skills allows them to monitor their own work and can improve the quality of data (Weeks et al., 2000). Based on problems identified in this study, training should emphasise increasing coverage rather than reducing wastage (that is, children should be vaccinated even when there are too few to use an entire vial), conducting defaulter tracing to reduce dropout, reducing missed opportunities for vaccination, and promoting time-management principles to maximise efficiency. Furthermore, the quality and quantity of supervision was reported to be lacking. Studies have shown that inadequate monitoring and supervision at all levels results in low immunisation coverage among the hard-to-reach, underserved and objectors, and that improving supervision can enhance coverage (Subramanyam and Sekhar, 1987; Joseph et al., 1988). Increasing both the quality of supervision by providing training in supportive supervision techniques, as well as the frequency of supervisory visits, should be prioritised. In addition to increasing Ministry of Health and Child Welfare resources, ZEPI could benefit potentially by developing partnerships at the national, district and local level, forming synergistic relationships and integrating with other services. Health workers at clinics may be able to share transport with local motorised extension officers working for aid or development agencies. Building strong public–private coalitions also may lead to more efficient use of limited resources (Morrow, Collins and Smith, 2007). Active community participation, which has been shown to im-prove vaccination coverage (Maher et al., 1993), was evident in this district and should be maintained. Conducting a local assessment that included in-depth interviews with various health workers and community leaders was critical to determine barriers affecting Gokwe South District. While vital in this location, many of the problems identified are likely to be widespread in other complex emergency settings. WHO’s ‘Reaching Every District’ strategy provides a useful framework for implementing best practice: re-establishing outreach services, conducting supportive supervision, establishing links to the community, monitoring and using data, and planning and managing resources (WHO, 2008). However, this strategy alone cannot ensure success, as it relies on sufficient existing resources and infrastructure for implementation of activi-ties. As has been seen previously, political unrest, civil strife and economic crisis cause breakdowns in health infrastructure, leading to extremely low immunisation coverage.3 In Afghanistan, for example, immunisation coverage failed to increase between 2000 and 2003 due to political instability, despite the presence of a relatively large number of vaccinators and vaccination centres (Mashal et al. 2007).

ConclusionEven though Zimbabwe finds itself in the midst of a dire economic and political crisis, adequate planning, innovation, motivation, and flexibility may lead to realistic and sustainable strategies to improve—or prevent further declines in—vaccination

TheneedforinnovativestrategiestoimproveimmunisationservicesinruralZimbabwe 171

coverage and other public health outcomes. Local assessments (situation analysis) are critical for identifying site-specific barriers to immunisation. These can be used to design innovative strategies that are needed to overcome existing challenges to immu-nisation programmes. Furthermore, immunisation policy should be flexible, allowing it to accommodate innovations meant to improve coverage, as long as adequate pre-cautions are put in place to preserve vaccine potency.

Acknowledgements The authors wish to express their sincere thanks for the contributions of all organisa-tions, health care workers and local communities that participated in the various stages of the study. The following were major contributors: Paradzai Kaseke (Provincial Medical Directorate, Midlands Province) and Regis Madungwe and Diamond T. Matiyenga (Gokwe District Hospital). The results were presented at the ‘Training in Epidemiology and Public Health Interventions Network–African Epidemiology Network Conference’ held in Kampala, Uganda, from 1–6 December 2007. The findings and conclusions reported here are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention, United States. There is no conflict of interest to declare.

CorrespondenceAddmore Chadambuka, Health Studies Office, P.O. Box CY1122, Causeway, Harare, Zimbabwe. E-mail: achadambuka1@yahoo.co.uk

Endnotes1 Addmore Chadambuka is a MPH (Master of Public Health) Trainee at the Department of Commu-

nity Medicine, University of Zimbabwe, Zimbabwe; Anderson Chimusoro is Provincial Medical

Director, Midlands Province, at the Ministry of Health and Child Welfare, Zimbabwe; Tsitsilina

Apollo is a Lecturer at the Department of Community Medicine, University of Zimbabwe, and

Assistant MPH Field Coordinator at the Ministry of Health and Child Welfare, Zimbabwe; Mufuta

Tshimanga is a Senior Lecturer at the Department of Community Medicine, University of Zimbabwe,

and MPH Field Coordinator at the Ministry of Health and Child Welfare, Zimbabwe; Olivia

Namusisi is Programmes Officer at the African Field Epidemiology Network, Uganda; and Elizabeth

T. Luman is an Epidemiologist at the Center for Global Health, US Centers for Disease Control

and Prevention, United States.2 See http://www.who.int/immunization_delivery/systems_policy/AFRO-RED-guide.pdf.3 See http://www.brown.edu/Courses/Bio_160/Projects1999/polio/polio2000A.html.

AddmoreChadambukaetal.172

ReferencesAlertNet (2008) Zimbabwe Crisis. 17 January. http://www.alertnet.org/db/crisisprofiles/zw_CRI.htm

(accessed on 13 April 2009).Anonymous (2008) ‘Medicine and conflict: Zimbabwe’s unsung heroes’. British Medical Journal. 337.

p. a1303.Anonymous, (2009) ‘A dismal year for human rights abuses’. The Lancet. 373(9660). p. 271.Bosu, W.K., D. Ahelegbe, E. Edum-Fotwe, K.A. Bainson and P.K. Turkson (1997) ‘Factors influ-

encing attendance to immunisation sessions for children in a rural district of Ghana’. Acta Tropica. 68(3). pp. 259–267.

Capp, C. (2009) ‘World report: Zimbabwe’s humanitarian crisis worsens’. The Lancet. 373(9662). p. 447.Central Intelligence Agency (2008) World Fact Book. http://www.cia.gov/library/publications/the-

world-factbook/geos/zi.html (accessed on 22 October Oct 2008)Coorey, S., J.R. Clausen, N. Funke, S. Munoz and B. Ould-Abdallah (2000) Lessons from High Inflation

Episodes for Stabilizing the Economy in Zimbabwe. IMF Working Paper No. WP/07/99. International Monetary Fund, Washington, DC.

International Monetary Fund (2009) ‘Statement at the conclusion of an IMF Article IV mission to Zimbabwe’. http://www.imf.org/external/np/sec/pr/2009/pr0993.htm (accessed on 13 April 2009).

Joseph, A. et al. (1988) ‘Improving immunisation coverage’. World Health Forum. 9(3). pp. 336–340.Koenig, R. (2009) ‘International groups battle cholera in Zimbabwe’. Science. 323(5916). pp. 860–861.Levine, A.C. (2008) ‘Global correspondent: world update’. Disaster Medicine and Public Health Preparedness.

2(1). pp. 17–19.Maher, C.P., J.J. Hall, W. Yakam, M. Naupa and D. Leonard (1993) ‘Improving vaccination coverage:

the experience of the Expanded Programme on Immunisation in Vanuatu’. Papua and New Guinea Medical Journal. 36(3). pp. 228–233.

Mashal, T, Kizuki M., Takano T., Nakamura K. and Seino K. (2007) ‘Impact of conflict on infant immunization coverage in Afghanistan: a country wide study 2000–2003’. International Journal of Health Geographics. 6:23. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1899486/pdf/1476-072X- 6-23.pdf (accessed on 21 April 2011).

Meldrum, A. (2008) ‘Zimbabwe’s health-care system struggles on’. The Lancet. 371(19618). pp. 1059–1060.Ministry of Health and Child Welfare (2000) EPI Multi-Year Plan 2001 –2005. Government of Zimbabwe,

Harare. Ministry of Health and Child Welfare (2004a) Evaluation and Five-year Plan for Replacement and Reha-

bilitation; EPI Cold-chain and Transport Equipment, Zimbabwe. Government of Zimbabwe, Harare.Ministry of Health and Child Welfare (2004b) National Health Information Unit. EPI Coverage Database. Ministry of Health and Child Welfare (2005a) EPI Policy Document. Ministry of Health and Child Welfare (2005b) Evaluation of Reaching Every District (RED) Approach in

Zimbabwe. Country Summary. June. Ministry of Health and Child Welfare (2005c) National Health Information Unit. EPI Coverage Database. Ministry of Health and Child Welfare (2005d) Zimbabwe. EPI Progress Report, January to December. Morrow, H., Collins B.K., and Smith D.R. (2007) ‘Public health coalitions: patterns and percep-

tions in state immunisation programs’. Journal of Health and Human Services Administration. 30(2). pp. 156–175.

Moss, W.J. et al. (2006) ‘Child health in complex emergencies’. Bulletin of the World Health Organization. 84(1). pp. 58–64.

Omutanyi, R.M. and Mwanthi M.A. (2005) ‘Determinants of immunisation coverage in Butere-Mumias District, Kenya’. East African Medical Journal. 82(10). pp. 501–505.

Physicians for Human Rights (2009) Health in Ruins: A Man-made Disaster in Zimbabwe. January. Physicians for Human Rights, Washington, DC.

TheneedforinnovativestrategiestoimproveimmunisationservicesinruralZimbabwe 173

Subramanyam, K. and Sekhar S.C. (1987) ‘Improving vaccine supplies to rural India’. Socio-Economic Planning Science. 21(2). pp. 131–138.

Teslik, L.H. (2008) Zimbabwe’s Economic Implosion. Analysis Brief. Council on Foreign Relations, New York, NY. http://www.cfr.org/africa/zimbabwes-economic-implosion/p14215 (accessed on 21 April 2011).

Toole, M.J., Steketee R.W., Waldman R.J. and Nieburg P. (1989) ‘Measles prevention and control in emergency settings’. Bulletin of the World Health Organization. 67(4). pp. 381–388.

Truscott, R. (2009) ‘Zimbabwe’s health challenges’. British Medical Journal. 338:b930. pp. 686–687.United Nations Statistics Division (2008) ‘Zimbabwe GDP’. National Accounts Main Aggregates

Database. http://millenniumindicators.un.org/unsd/snaama/SelectionCountry.asp (accessed on 22 October 2008).

Weeks, R.M., Svetlana F., Noorgoul S., and Valentina G. (2000) ‘Improving the monitoring of immunisation services in Kyrgyzstan’. Health Policy Plan. 15(3). pp. 279–286.

WHO (World Health Organization) (2002) Immunization, Vaccines and Biologicals. The Common Assessment Tool for Immunisation Services. http://www.who.int/vaccines-documents/DocsPDF05/CAT/Bklt1_10_12.pdf (accessed on 22 October 2008).

WHO (2006) Mortality Country Fact Sheet 2006. http://www.who.int/whosis/mort/profiles/mort_afro_zwe_zimbabwe.pdf (accessed on 13 April 2009)

WHO (2009a) ‘Daily cholera update and alerts’. 4 April. http://www.who.int/hac/crises/zwe/sitreps/zimbabwe_cholera_update_4apr2009.pdf (accessed on 13 April 2009).

WHO (2009b) ‘Core health indicators’. http://www.who.int/whosis/database/core (accessed on 13 April 2009).

WHO and UNICEF (United Nations Children’s Fund) (2005) ‘GIVS: Global Immunization Vision and Strategy 2006–2015’. http://whqlibdoc.who.int/hq/2005/WHO_IVB_05.05.pdf (accessed on 21 April 2011).

WHO and UNICEF (2010) ‘Estimates of immunisation coverage: Zimbabwe’. http://www.who.int/vaccines/globalsummary/immunisation/timeseries/tswucoveragebycountry.cfm?country=ZWE (accessed on 21 April 2011).

World Bank (2009) Zimbabwe: Country Brief. http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/AFRICAEXT/ZIMBABWEEXTN/0,,menuPK:375746~pagePK:141132~piPK:141107~theSitePK:375736,00.html (accessed on 13 April 2009).

World Medical Association (2007) WMA Resolution on Health and Human Rights Abuses in Zimbabwe. http://www.wma.net/en/30publications/10policies/a29/index.html (accessed on 21 April 2011).